Brief Description of Measure:

CMS135: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD):Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB or ARNI therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge
CMS144: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD):
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

Description of Issue:

​Per the technical expert panel, there is nationwide access to these medications and all health systems can provide for beta-blocker and ACE inhibitor, ARB, or ARNI therapy in-hospital, hospital discharge and/or outpatient. Because of the wide availability, there is not an applicable system-based reason that a US health system either in the inpatient or outpatient setting could not provide these therapies.
 
Therefore, the system reason exception is no longer a valid denominator exception, and is being proposed for removal, both from the measure header and logic.

Proposed Solution:

REMOVE THE FOLLOWING DENOMINATOR EXCEPTION LANGUAGE FOR 135:
…Documentation of system reason(s) for not prescribing ACE inhibitor or ARB or ARNI therapy (e.g., other system reasons).
 
CURRENT LOGIC FOR 135:
Population 1
Denominator Exceptions
   "Has Medical Patient or System Reason for Not Ordering ACEI or ARB or ARNI Outpatient"
     or …
 
Has Medical Patient or System Reason for Not Ordering ACEI or ARB or ARNI Outpatient
   exists ["Medication, Not Ordered": "ACE Inhibitor or ARB or ARNI"] NoACEIOrARBOrARNIOrdered
     with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
       such that NoACEIOrARBOrARNIOrdered.authorDatetime during ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
     where ( NoACEIOrARBOrARNIOrdered.negationRationale in "Medical Reason"
         or NoACEIOrARBOrARNIOrdered.negationRationale in "Patient Reason"
         or NoACEIOrARBOrARNIOrdered.negationRationale in "Patient Reason for ACE Inhibitor or ARB Decline"
         or NoACEIOrARBOrARNIOrdered.negationRationale in "System Reason"
)
 
Population 2
Denominator Exceptions
   "Has Medical Patient or System Reason for No ACEI or ARB or ARNI at Inpatient Discharge"
     or …
 
Has Medical Patient or System Reason for No ACEI or ARB or ARNI at Inpatient Discharge
   exists ["Medication, Not Discharged": "ACE Inhibitor or ARB or ARNI"] NoACEIOrARBOrARNIAtDischarge
     with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
       such that NoACEIOrARBOrARNIAtDischarge.authorDatetime during ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
     where ( NoACEIOrARBOrARNIAtDischarge.negationRationale in "Medical Reason"
         or NoACEIOrARBOrARNIAtDischarge.negationRationale in "Patient Reason"
         or NoACEIOrARBOrARNIAtDischarge.negationRationale in "Patient Reason for ACE Inhibitor or ARB Decline"
         or NoACEIOrARBOrARNIOrdered.negationRationale in "System Reason"
)
 
PROPOSED LOGIC FOR 135:
Population 1
Denominator Exceptions
   "Has Medical or Patient Reason for Not Ordering ACEI or ARB or ARNI Outpatient"
     or …
 
Has Medical or Patient Reason for Not Ordering ACEI or ARB or ARNI Outpatient
   exists ["Medication, Not Ordered": "ACE Inhibitor or ARB or ARNI"] NoACEIOrARBOrARNIOrdered
     with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
       such that NoACEIOrARBOrARNIOrdered.authorDatetime during ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
     where ( NoACEIOrARBOrARNIOrdered.negationRationale in "Medical Reason"
         or NoACEIOrARBOrARNIOrdered.negationRationale in "Patient Reason"
         or NoACEIOrARBOrARNIOrdered.negationRationale in "Patient Reason for ACE Inhibitor or ARB Decline")
 
Population 2
Denominator Exceptions
   "Has Medical or Patient Reason for No ACEI or ARB or ARNI at Inpatient Discharge"
     or …
 
Has Medical or Patient Reason for No ACEI or ARB or ARNI at Inpatient Discharge
   exists ["Medication, Not Discharged": "ACE Inhibitor or ARB or ARNI"] NoACEIOrARBOrARNIAtDischarge
     with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
       such that NoACEIOrARBOrARNIAtDischarge.authorDatetime during ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
     where ( NoACEIOrARBOrARNIAtDischarge.negationRationale in "Medical Reason"
         or NoACEIOrARBOrARNIAtDischarge.negationRationale in "Patient Reason"
         or NoACEIOrARBOrARNIAtDischarge.negationRationale in "Patient Reason for ACE Inhibitor or ARB Decline")
 
REMOVE THE FOLLOWING DENOMINATOR EXCEPTION LANGUAGE FOR 144:
… Documentation of system reason(s) for not prescribing beta-blocker therapy (e.g., other reasons attributable to the healthcare system).
 
CURRENT LOGIC FOR 144:
Population 1
Denominator Exceptions
"Has Consecutive Heart Rates Less than 50 Outpatient"
  or "Has Medical Patient or System Reason for Not Ordering Beta Blocker for LVSD Outpatient"
…
 
Has Medical Patient or System Reason for Not Ordering Beta Blocker for LVSD Outpatient
   exists ["Medication, Not Ordered": "Beta Blocker Therapy for LVSD"] NoBetaBlockerOrdered
     with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
       such that NoBetaBlockerOrdered.authorDatetime during ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
     where ( NoBetaBlockerOrdered.negationRationale in "Medical Reason"
         or NoBetaBlockerOrdered.negationRationale in "Patient Reason"
         or NoBetaBlockerAtDischarge.negationRationale in "System Reason")
 
Population 2
Denominator Exceptions
   "Has Consecutive Heart Rates Less than 50 Inpatient"
     or "Has Medical Patient or System Reason for No Beta Blocker for LVSD at Inpatient Discharge"
…
 
Has Medical Patient or System Reason for No Beta Blocker for LVSD at Inpatient Discharge
   exists ["Medication, Not Discharged": "Beta Blocker Therapy for LVSD"] NoBetaBlockerAtDischarge
     with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
       such that NoBetaBlockerAtDischarge.authorDatetime during ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
     where ( NoBetaBlockerAtDischarge.negationRationale in "Medical Reason"
         or NoBetaBlockerAtDischarge.negationRationale in "Patient Reason"
         or NoBetaBlockerAtDischarge.negationRationale in "System Reason")
 
 
PROPOSED LOGIC FOR 144:
Population 1
Denominator Exceptions
"Has Consecutive Heart Rates Less than 50 Outpatient"
  or "Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD Outpatient"
…
 
Has Medical or Patient Reason for Not Ordering Beta Blocker for LVSD Outpatient
   exists ["Medication, Not Ordered": "Beta Blocker Therapy for LVSD"] NoBetaBlockerOrdered
     with "Heart Failure Outpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFOutpatientEncounter
       such that NoBetaBlockerOrdered.authorDatetime during ModerateOrSevereLVSDHFOutpatientEncounter.relevantPeriod
     where ( NoBetaBlockerOrdered.negationRationale in "Medical Reason"
         or NoBetaBlockerOrdered.negationRationale in "Patient Reason")
 
Population 2
Denominator Exceptions
   "Has Consecutive Heart Rates Less than 50 Inpatient"
     or "Has Medical or Patient Reason for No Beta Blocker for LVSD at Inpatient Discharge"
…
 
Has Medical or Patient Reason for No Beta Blocker for LVSD at Inpatient Discharge
   exists ["Medication, Not Discharged": "Beta Blocker Therapy for LVSD"] NoBetaBlockerAtDischarge
     with "Heart Failure Inpatient Encounter with Moderate or Severe LVSD" ModerateOrSevereLVSDHFInpatientEncounter
       such that NoBetaBlockerAtDischarge.authorDatetime during ModerateOrSevereLVSDHFInpatientEncounter.relevantPeriod
     where ( NoBetaBlockerAtDischarge.negationRationale in "Medical Reason"
         or NoBetaBlockerAtDischarge.negationRationale in "Patient Reason")

Rationale for Change:

Due to the wide availability of the medications addressed by these measures, both in the inpatient and outpatient settings, the system reason exception is no longer relevant.